By signing this form today, I agree I am the owner or agent for the owner of the pet I am presenting for evaluation today and have the authority to sign (am 18 years of age or older), comply, and consent to the procedures described to me as well as provide timely payment for services. I understand that privacy laws prohibit Hickory Veterinary and Specialty Hospital (HVSH) from speaking to anyone not listed on my pet’s account. I further understand that HVSH can only provide updates to one person throughout a hospitalization to provide continuity in communication and care.

All professional fees are due at the time services are rendered with a 75% deposit of the high end of the estimate required to begin diagnostics and/or treatment, which must be maintained throughout my pet’s hospitalization should additional estimates be required. We urge you to discuss all fees with the doctor before services are performed. I understand estimates provided could fluctuate +/- 25%. The balance is due at the time the patient is discharged from the hospital. We accept cash, all major credit cards, and checks (with proper ID). Financial assistance is available via CareCredit or Scratch Pay and could be discussed with a Client Service Representative if interested in applying. There will be a service charge for any check returned unpaid. We are unable to extend credit.

The sale of all medications and prescription products/food are final. To comply with PA and risk management guidelines, all pharmacy items are non-returnable. This policy is necessary to protect your pet from items that may have been tampered with, stored improperly, or used improperly. Furthermore, I understand I have the right to ask for prices, expiration dates, duration of use, etc. before taking medications out of the hospital, and to ask for written prescriptions to take with me or to be sent to a pharmacy of my choice to be filled.

A deposit may be required to reschedule an appointment if canceling within 24 hours of the appointment time or if multiple cancellations have been encountered by our specialty departments. The required deposit to reschedule the appointment will be explained at the time the request to rebook is made.

I hereby authorize the veterinarians at Hickory Veterinary and Specialty Hospital to examine, treat and prescribe medications to my pet. I agree to assume all financial responsibility for all charges incurred in the care of my pet. I further understand that I am responsible for services and/or products not paid for at the time of discharge that were incurred during the exam or hospitalization with HVSH.

I have read and understand this authorization and consent. I, the undersigned, have read and agree to the above financial policy; and I understand my financial obligation. Further, I agree to pay all reasonable attorney fees and all costs and expenses which may be incurred by a collection agency in the enforcement of this agreement.

THIS HOSPITAL IS A HEALING ENVIRONMENT

We understand that these are stressful times, and that having a sick or injured pet is particularly stressful.

Our team is working hard, under difficult conditions, and they are 100% committed to being here for your pet. They will treat you with courtesy, compassion and respect. We expect that they be treated in the same manner so that we can properly attend to the needs of your pet.

The sale of all medications and prescription products/food are final. To comply with PA and risk management guidelines, all pharmacy items are non-returnable. This policy is necessary to protect your pet from items that may have been tampered with, stored improperly, or used improperly. Furthermore, I understand I have the right to ask for prices, expiration dates, duration of use, etc. before taking medications out of the hospital, and to ask for written prescriptions to take with me or to be sent to a pharmacy of my choice to be filled.

HVSH has zero tolerance for unprofessional, disrespectful or aggressive language or behavior, including failure to respond to instructions and safety recommendations. Out of respect for our patients, team and clients, any incidents may result in refusal to treat and removal from our facility. When appropriate, hospital leadership will support our team members in pressing charges.